[Additional file 1]Treatment of mental disorders and psychological problems has a long and often chequered history in our country. While Departments of Psychiatry have rapidly proliferated over the past three decades, psychotherapy remains a fledgling discipline and its use in day-to-day clinical practice continues to be an exception rather than the rule. Several reasons can be offered as explanations for this marked disinclination to use psychotherapy in routine practice, a major one being what the authors of the book under review refer to as the 'pharmacologization of mental healthcare in India'. Undoubtedly this phenomenon has played a significant role in the tendency for most practitioners to reach for a prescription pad rather than offering an empathic relationship to work through the problems proffered by distressed patients. Another important reason that has proved to be a stumbling block for aspiring psychotherapists has been the lack of well-structured training programs in psychotherapy. Barring a few centers, most departments have little to offer by way of training, and even less so, of supervision and resource materials. The interested trainee perforce has to fall back on western text books of psychotherapy and the sparse literature, mostly in the form of journal articles, which have described Indian experiences. In this rather bleak landscape, the authors V.K. Varma and Nitin Gupta deserve to be complimented for undertaking the task of compiling their experiences and ideas in the form of a book. It is a pioneering effort, as it attempts to document the practice of psychotherapy entirely from the Indian perspective, taking cognizance of the realities, characteristics, and needs of our clientele, as well as the difficulties inherent in this endeavor. The first author needs no introduction to the Indian audience, given his vast professional experience as an academician and researcher in one of the foremost training centers for psychiatry in the country.

The book, attractively titled as, "Psychotherapy in a Traditional Society: Context, Concept, and Practice," is divided into four sections. Section 1 describes the theoretical and conceptual basis of transcultural psychiatry and comprises of six chapters delving into these issues. Section 2 describes the practice of individual psychotherapy in our socio-cultural milieu. Section 3 reviews the role of other therapeutic techniques as well as the issue of psychotherapy integration and eclecticism. Section 4 outlines a model for psychotherapy in our context and the future directions.

Section 1 begins by defining and describing the characteristics of psychotherapy as understood and practiced in the west. Psychotherapy is then compared to other traditional healing relationships, highlighting their commonalities. Socio-cultural factors, relevant to the practice of psychotherapy, are discussed including aspects such as dependence versus autonomy, psychological sophistication, patients' expectations, and the role of the family, to name a few. Ancient Indian concepts of mind, personality, mental health, and psychotherapy are described, which is followed by a discussion of the state of psychotherapy as practiced in India currently. While describing the role of general practitioners, indigenous doctors, and lay therapists, there is a surprising reference to clinical psychologists, psychiatric social workers, and psychiatric nurses as 'lay therapists'. The use of the term 'lay therapists' to describe these professionals is regretful. The term 'lay therapist' is generally used to refer to those with no professional knowledge or training in a specific field or to those counsellors who are authorized by the Church to undertake counselling. Therefore, the use of this term does gross injustice to other non-medical professionals in the field of mental health, by glossing over the many years of their professional training. One hopes that this has been an oversight on the part of the authors and not a Freudian slip! Tracing the evolution of human civilization, the authors discuss some of the 'mental health strains' of the future. A rather conspicuous omission in this section is the impact of the liberalizing economy on the social fabric of the country. On the other hand, the possible consequences on personal identity and responsibility, of genetic engineering and organ transplant, have been included, although the number of individuals likely to be impacted by these procedures would obviously be far fewer. In fact, the deleterious consequences of rapid social changes on mental health have already become obvious to mental health professionals. This section concludes with a reprinting of a seminal article by the first author on the 'Cultural psychodynamics in health and illness'.

Section 2 describes the actual practice of psychotherapy in our setting. The general principles and criteria adopted for selection of the cases for therapy, the relative contraindications for therapy as well as the processes involved in selecting and undertaking psychotherapy are clearly spelled out. Ten selected cases are then described. Each vignette begins with a brief history and background details of the patient, followed by a provisional formulation, mainly based on the psychodynamic framework. The treatment plan and course of therapy, which includes brief descriptions of each session, are provided and each case concludes with a commentary summarizing the formulation and the therapy process, as well as highlighting a specific aspect of the process, which differed from western practices.

Section 3 provides good overviews of what the authors describe as 'other non-dynamic psychotherapeutic techniques'. These include methods such as relaxation methods, yoga, Vipassana meditation, Transcendental meditation, and autogenic training. Each of these techniques have been reviewed by invited authors who have clearly articulated the techniques, their rationale, effects, and available evidence in support of their efficacy or otherwise. While many of these techniques have no doubt, proven useful in alleviating many of the symptoms of emotional disorders, it is a moot point whether these methods can be classified as 'psychotherapy' in the real sense of the term. It must be mentioned that the authors all through the book argue for broadening the definition of psychotherapy to include methods (and practitioners) that have social sanction and acceptance in a given culture. This perhaps justifies their inclusion of the methods alluded to a little earlier in the text.

The final section deals with the issue of development of an 'Indian model' of psychotherapy and future directions. Therefore it is baffling why issues such as, 'the need for psychotherapy' and 'what is psychotherapy' are discussed at the very end of the book rather than in the first section itself. The authors discuss the issue of psychotherapy from a public health perspective. As a means of bridging the yawning gulf between the mental needs in the community and the resources available, they advocate training of health workers as well as graduate and postgraduate trainees in psychology and social work in the necessary skills. The question that arises here is whether it is necessary to disseminate psychotherapeutic skills so widely when even basic mental healthcare needs have not been satisfactorily addressed. In any case, this scenario appears to be emerging already in the country, exemplified by the numerous courses in counselling that have been initiated in recent times. However, in the absence of any mechanism to monitor the quality of the training and accreditation of these practitioners, such trends can backfire. The authors have very rightly emphasized these issues as well as highlighted the need for a statutory body to ensure the highest standards in training and practice.

Neophyte psychotherapists will find in this book a good introduction to the ideas and seminal articles of the first author. It is also a comprehensive source of references for most of the other landmark articles on various aspects of psychotherapy in the country. However, those seeking to improve their therapeutic skills or to deepen their understanding of how psychodynamic concepts are actually played out in our context will find the book disappointing. Section III in which case vignettes are described offers the perfect opportunity for this. However, the description of each session is too brief to provide any understanding of the therapeutic processes that would have transpired. Sessions have focused mainly on the content and do not provide any account of the therapists' responses. It would have been immensely useful if process issues such as obstacles for formation of a therapeutic alliance, challenges to therapists' own belief and value systems, change processes, and so on, had been dealt with in detail. Perhaps constraints of space and length precluded such a description. However, if the complete transcript of even one case had been used to illustrate these issues, it would have provided invaluable insights. It would also have been extremely valuable if the authors (particularly the senior author) had shared their vast experience of issues in the supervisory process, as this would have greatly benefited other trainers who have little to fall back on by way of Indian experiences. The book would have also benefited by more stringent editing, Section I is fairly repetitious: ideas as well as many statements and quotations appear in more than one chapter which hampers easy reading.

At the end, one is left with a sense of having one's appetite whetted, but not fully satisfied. Most professionals practicing psychotherapy in this country have adapted western models to suit the needs of their clients and their contexts. Very few, however, have come forward to share these experiences openly, perhaps out of apprehensions of disapproval or being faulted by their co-professionals. Kudos, therefore to the authors for undertaking this significant venture and initiating the first step in this direction. It is only when many such experiences are shared will the contours of an 'Indian model' of psychotherapy finally emerge.

Correspondence Address:Ahalya RaguramDepartment of Mental Health and Social Psychology, National Institute of Mental Health and Neuro Sciences, (NIMHANS) Bangalore India